California Licensed Documentation Specialist

Job Summary

Working remotely in a full-time capacity, the California Licensed Documentation Specialist will review medical records to ensure accuracy and completeness, assist in clinical documentation improvement initiatives, and support regulatory compliance through audits and training programs.

Key responsibilities:

• Conduct clinical documentation reviews and assign medical codes and DRGs to enhance documentation accuracy
• Integrate processes to improve clinical documentation and collaborate on documentation improvement initiatives
• Facilitate staff training on clinical documentation standards and ensure adherence to regulatory compliance

Required qualifications:

• Minimum two (2) years of experience in an inpatient acute care or clinical setting
• Bachelor's degree in Nursing, Medicine, Health Administration, Health Information Management, or a related field, with additional experience requirements
• California Physician Assistant License, Doctor of Medicine License, Nurse Practitioner Certificate, or Registered Nurse License required at hire